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The Incident

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Autopsy

2/14/1999 St. Jennifers Med Center Viv Sexton M.D. Pathologist Autopsy Report Final Anatomic Diagnoses: 1. Massive pulmonary embolus. 2. Benign rignt renal cortical cyst. 3. Benign right cortical adenoma. 4. Grade I cornoary artery atherosclerosis. a. Left ventricular hypertrophy. b. Clinical hypertension. 5. Obesity. a. Clinical diabetes. 6. Fatty metamorphosis, liver. 7. S/P colon resection secondary to ruptured diverticulum (1-96).

Notandum: Death in this case was secondary to massive pulmonary embolus which occluded both pulmonary arteries. The circumferences of both calves of the deceased were measured and were found to be equal, and there was no evidence of induration or edema. This suggests that the deep pelvic vessels were the source of the emboli.

Introduction: Mr Hart was a 46-year old Caucasian who first presented on 02/13/99 with five minutes of chest tightness and diaphoresis. The patient also sensed some irregularity in his heart beat. The pain did not radiate. The diaphoresis had been present on and off for a week along with symptoms of gastroenteritis. He had had no previous cardiac symptoms, althoug he was hypertensive. He had a long history of cigarette smoking, but had stopped about five years previous to admission. There was no family history of cardiac disease. Other past medical history includes colon resection secondary toruptured diverticulum, diabetes, hypertension, renal stones with lithotripsy and obesity. Current medications include Zestril (10 mg q.i.d.) and Glucotrol. Physical examination on admission showed an increased blood pressure, tachycardia of 100 to 115 with rare ectopic beats. Paramedics who transported him noted bigeminy with exertion. HIs abdominal exam was unremarkable. His EKG showed no changes suggestive of acute MI. He was admitted for monitoring and to rule-out myocardial infarction. Admission laboratory examinations included a cholesterol of 215 mg/dl with and HDL of 20 mg/dl, potassium of 5.05 mmol/L, total CK of 27 IU/L, and a pH of 7.39. Monitoring showed rare to occasional PVCs. He had a second episode of mild chest tightness and shortness of breath with a feeling of fear. Myocardial infarction was ruled-out and the patient was discharged on 02/14/98 with nitroglycerin and instruction for its use. On 02/14/98, one hour after discharge, the patient called 911 due to shortness of breath. The paramedics arrived to find the patient suffering from severe dyspnea. He then went into respiratory arrest and asystole. A full resuscitative protocol was carried out, including a temporary pacemaker. The efforts were unsuccessful and the patient expired at 1245 hours on 02/14/98. An autopsy is performed in the morgue of St. Jennifers Med Center by Viv Sexton, M.D. on 02/14/98 at 1500 hours.

External Examination: The body is that of a well-nourished, well-developed Caucasian who appears documented age of 46 years. Rigor is absent in the extremities. There is minimal unfixed livor in the dorsal soft tissues. Jaundice is absent; edema is absent. The body measure 67 inches and weights approximately 275 pounds. Scalp hair is curly, dark brown and approximately 3-4 inches long. Irides are brown; sclerae are white. Pupils are round, symmetric and measure 6 mm. each. the eyes, ears, nose and mouth are unremarkable. the neck is grossly normla. The chest is normal in size and configuration. Breasts are grossly normal. The abdomen is obese and displays a 47 cm., well-healed, mid line surgical scar beginning just below the xiphoid. Genitalia are those of a normal adult. The upper and lower extremities are free of deformity. The dorsal soft tissues are consistent with age group.

Internal Examination: The body is opened in the routine Y-fasion revealing subcutaneous fat which is yellow, normal in texture and measures 6 cm at the umbilicus. The abdominal organs have a normal situs. The cavity contains no blood and multiple thin adhesions. The chest plate is removed; it is intact. Both pleural spaces show no blood, no fluid, and no adhesions. The pericardial sac is opened ventrally revealing small amount of clear yellow fluid and a smooth epicardium.

Heart: The heart weighs 400 grams and has a smooth epicardial surface. Sectioning of the coronary arteries reveals Grade I atherosclerosis of the right coronary and left anterior descending. The system is right dominant. Cross-sectioning reveals grossly normal red-brown myocardium. The right ventricular wall measures .4 cm. and the left ventricular wall measure 1.9 cm. The heart is opened in the direction of the flow of blood revealing grossly normal tricuspid, pulmonic, mitral and aortic vavles. There is no evidence of acute or healed infarction.

Lungs: The right lung weights 350 grams and the left lung weighs 350 grams. The trachea and bronchioles are unobstructed. The pulmonary arteries contain obstructive thrombi (so-called saddle embolism) which fully obstruct both the right and left pulmonary arteris. The veins are unremarkable. Both pleural surfaces show minimal anthracotic mottlin. Cross-sectioning reveals somewhat congested airless parenchyma.

Gastrointestinal Tract: The esophagus i normal throughout its length with an intact mucosa. The stomach contains granular gray material which is removed revealing a normal mucosa. The large and small bowels show evidence of previous colonic resection. The appendix is absent.

Hepatobillary System: The liver weights 2,100 grams, has an intact capsule and greasy, yellow-brown parenchyma. The gallbladder contains viscous, green-black bile and no stones.

Spleen: The spleen wieghs 140 grams, has an intact capsule and normal deep purple parenchyma.

Pancreas: The pancreas is normal in size and shape with the usual nodular tan parenchyma.

Adrenals: Both adrenal glands are normal in size and shap with a .8 cm. cortical adenoma involving the right adrenal gland.

Kidneys: The right kidney weights 120 grams; the left kidney weighs 120 grams. Both capsules are thin and strip easily. Both ureters are patent. Renal arteris are free of stenosis. Longitudinal sectioning reveals grossly normal parenchyma. There is a 2 cm. cyst of the upper pole of the right kidney containing clear yellows fluid.

Urinary Bladder: The bladder contains a small amount of clear yellow fluid and is grossly normal.

Aorta: The aorta is opened revealing mild atherosclerosis.

Head: The head is not examined.
Samples are taken of blood. Tissue samples are retained with no microscopic exam at this time.